How To Write Assessments in Medicine

An assessment communicates, in summary form, the results of the information gathering process, through history, examination and investigations, the current diagnoses of the team regarding the patient.

A good assessment is organized by relevance and provides for each diagnosis listed the degree of acuity therefore informing the sequence of the actions in the plan.

The assessment thus synthesizes pieces of information into a coherent whole. It is moving and dynamic but also grounding. The acute condition may be resolved, but some other condition for example, the patient’s uncontrolled Diabetes may still extend the hospital stay.

Here are some tips on how to write assessments:

Prioritize, but be complete.

Determine what is the most important or most acute condition and put it first. However ensure to be comprehensive with your assessment list.

An assessment isn’t static. As the patient  continues in the admission more and more information will be gathered and therefore the initial assessment should be increasingly honed and perfected.

example

Mary A, 69 yo F is Diabetic and presents with a fall from standing height and pain to Left hip. Labs show anemia, low albumin; random central glucose is 20mmol/L. X ray confirms L hip fracture.

Assessment:

1. Left hip fracture

2. Uncontrolled DM

3. Anaemia ? Cause

4. Hypoalbuminaemia ? Cause

No problem left behind.

Make reasonable attempts to account for every problem that the patient has. Unaccounted for problems, often denoted shorthand as Query cause…should make you uncomfortable, like a stone in your shoe.

example continued

Mary A’s fracture pattern is reviewed, it appears pathologic. Further labs are ordered, confirming elevated calcium and markedly elevated total protein. She is given over 4L of intravenous fluid each day for 3 days and on day 4 is noted to be dyspneic.

Assessment

1. Likely fluid overload-iatrogenic (not dyspnea? Cause)

2. Pathologic L hip fracture

3. Uncontrolled DM 

4. Anemia ? Cause   

5. Hypercalcemia ? Cause 

Use connectors and qualifiers.

Words such as complicated by, secondary to, presumed help to bind up the problems into a cohesive diagnosis. 

example continued

Mary A’s additional workup suggests Multiple Myeloma. She receives intravenous furosemide and her dyspnea resolves.

Assessment

1. Presumed Multiple Myeloma complicated by L hip fracture-pathologic

2. Moderate Anaemia of inflammation

3. Moderate hypercalcemia – resolved

4. Iatrogenic fluid overload- resolved

5. Uncontrolled DM

Dont be left behind! 

Progress notes are just that, really a catalogue of directional movement. ‘Stable’ is probably a better descriptor for vitals than is it for problems. Be as descriptive with adjectives used for the problems. The assessment should convey almost optically a snapshot of the patients state.

Example continued

Mary A has her hip replacement carried out and is deemed ready for discharge but has been on sliding scale insulin for her diabetic control with GMRs  in the high teens to twenties.

Assessment 

1. Presumed Multiple Myeloma complicated by Pathologic L hip fracture status post ORIF

2. Moderate hypercalcemia resolved

3. Moderate Anemia of inflammation 

4. Moderately uncontrolled DM

5. Iatrogenic fluid overload- resolved

Keep practicing

Keep reading, keep assessing. This will increase the sophistication  and the “economy” of your assessment, that is your assessments will be increasingly meaningful and succinct.

example continued

Mary A’s has finally got to the point of discharge! Her metabolic issues have been addressed with targeted therapy for her elevated calcium and blood sugar. Her discharge assessment 

Assessment:

1. Presumed Multiple myeloma complicated by Pathologic Left Hip fracture status post ORIF

2. Moderate hypercalcemia now resolved 

3. Moderate anemia

4. Diabetes Mellitus controlled

5. Iatrogenic fluid overload- resolved

Dr. Ryan Brooks

Thank you Dr. Brooks for contributing this article for medical students, new doctors and even more experienced doctors! If you would like to contribute an article to The Layman’s Doctor send an email to thelaymansdoctor@gmail.com.